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The health migration crisis: the role of four Organisation for Economic Cooperation and Development countries
Public Health
The health migration crisis: the role of four Organisation for Economic Cooperation and Development countries Bob Pond , Barbara McPake Lancet 2006; 367: 1448–55 Published Online March 21, 2006 DOI:10.1016/S01406736(06)68346-3 Avenue du Vieux Bourg 48, CH-1225 Chêne-Bourg, Switzerland (B Pond MD); and Institute for International Health and Development, Queen Margaret University College, Edinburgh EH12 8TS, UK (Prof B McPake PhD) Correspondence to: Prof Barbara McPake [email protected]
OECD The organisation for Economic Cooperation and Development is a group of 30 member countries that share a commitment to democratic government and market economy.
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The crisis of human resources for health that is affecting low-income countries and especially sub-Saharan Africa has been attributed, at least in part, to increasing rates of migration of qualified health staff to high-income countries. We describe the conditions in four Organisation for Economic Cooperation and Development (OECD) health labour markets that have led to increasing rates of immigration. Popular explanations of these trends include ageing populations, growing incomes, and feminisation of the health workforce. Although these explanations form part of the larger picture, analysis of the forces operating in the four countries suggests that specific policy measures largely unrelated to these factors have driven growing demand for health staff. On this basis we argue that specific policy measures are equally capable of reversing these trends and avoiding the exploitation of low-income countries’ scarce resources. These policies should seek to ensure local stability in health labour markets so that shortages of staff are not solved via the international brain drain. High rates of emigration from low-income and middleincome countries to those with higher incomes is one cause of a human resource crisis in health that is most acutely affecting the poorest parts of the lowest-income countries. Recent rises in such emigration have been documented for countries such as Ghana1–3 and South Africa,4–7 but incomplete and not fully comparable statistics have resulted in difficulty in analysing trends and comparing the parts played by most source and destination countries.8 Statistics for registration or qualification of nurses migrating to five countries show that since the mid 1990s there have been surges in the recruitment of overseas nurses to the UK and Ireland, less pronounced increases for the USA and Australia, and stable or falling levels for Norway.9 These recent rises in migration of health workers to some high-income countries indicate, in part, long-term demographic, economic, and workforce trends in Organisation for Economic Cooperation and Development (OECD) countries. In these countries, ageing populations and growing incomes feed the demand for health services whereas the ageing and feminisation of the health workforce combined with a rising preference for leisure time reduce the supply of health services.9–12 Hence some analysts point to the recent rise in immigration as evidence of major and enduring global shortages in nurses and doctors over the next decades.13–15 However, such long-term gradual trends cannot explain the abrupt surges in immigration of health workers to some countries, or why there is considerable variation between high-income countries in the levels and trends of immigration. Moreover, past projections of the supply and demand for health workers in several countries have proven that workforce prediction is a highly imperfect science.16–18 Analysis of the evolution of the current conditions in labour markets in OECD countries could provide insights and opportunities for policy to improve the global distribution of human resources. We review the evolution over recent decades of the supply and demand for physicians and nurses in four OECD
countries: the UK, the USA, France, and Germany. We look at key trends in the production, remuneration, and retention of health professionals as well as the factors that shape them. The aim is to provide a better understanding of migration of physicians and nurses from low-income countries. Physicians and nurses intending to work in the UK must first register with the General Medical Council and the Nursing and Midwifery Council, respectively, and each of these organisations keeps statistics on the country of education. Physicians have to complete a postgraduate residency training to practise in the USA. Cooper19 estimated levels and trends in number of international medical graduates by subtracting the number of medical school graduates from the number of physicians entering postgraduate training. Statistics on levels and trends in USA licensing of physicians from sub-Saharan Africa were extracted from the American Medical Association physician masterfile which records the date of first licensure and country of education of all physicians.20 For international medical graduates there is an average lag of 2 to 3 years between the time that they begin residency training and the time that they are first licensed. Rather than attempt to adjust for this lag, the unadjusted data are presented. International nursing graduates have to pass the national licensure examination for registered nurses before they are licensed in the USA, and statistics are available for their country of education.21 Statistics by country of education for the numbers passing this examination are available only for those taking the examination for the first time. Total passes of nurses trained in sub-Saharan Africa were estimated by assuming that the ratio of total passes to first-time passes was the same every year, as for all international nursing graduates taking the exam (range=1·4–1·6). The Conseil National de l’Ordre des Médecins22,23 and the Bundesärztekammer,24 the national medical associations of France and Germany, respectively, maintain rosters indicating the nationality of physicians with full working privileges. www.thelancet.com Vol 367 April 29, 2006
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Although these statistics on physician stocks are available for each year from 1998 to the present, they do not directly indicate the number of newly licensed health workers, and they underestimate the number of immigrant health workers because they show current nationality rather than country of education. Moreover, official French statistics omit a sizeable number of physicians trained outside the EU who work in French hospitals without full privileges. The French system allows few opportunities to practise in the public hospital system on a short-term contractual basis, and without the status of a fully medically qualified practitioner. The provisions have gradually broadened, and since 1999, include the possibility of authorisation to practise general medicine, but permission had been extended to very small numbers by 2001.22 The analysis of immigration of doctors to France is therefore based on the rough approximations made in an authoritative workforce projection document.18
Supply and demand for health workers in OECD countries Statistics from WHO’s Global human resources for health atlas25 suggest that the UK ranks among the least staffed of high-income countries, with 166 doctors and 497 nurses per 100 000 population (table 1)25–29—the second lowest doctor density (ahead of Turkey) and fourth lowest nurse density (ahead of Greece, Spain, and Turkey) of all OECD countries. However, this comparison seems to be misleading. Buchan27 reports that the official OECD figure for practising nurses counts only those working in the National Health Service (NHS) in England and Wales, although the UK population is used as the denominator. Approximately 270 000 nurses are counted, whereas if those working outside the NHS and in Scotland and Northern Ireland are included, the total would be about 390 000. This recalculation increases the nurse per 100 000 population ratio to approximately 650, ranking the UK closer to the middle of the European range. The election of the Labour government in the UK in 1997 was followed by a sharp rise in the rate of growth of expenditure on the NHS beginning in 1998. Government health officials set targets to substantially increase the number of nurses and doctors. For example, the number of nurses working for the NHS in England was set to increase by 20 000 (6%) between 1999 and 2004,30 and when this target was reached early, the government set a new target to increase nurses by 35 000 (10%), and general practitioners and consultants by 15 000 (25%) between 2001 and 2008. Several strategies were adopted to increase staffing: (1) retention of current staff and return of those working elsewhere; (2) recruitment of newly qualified health professionals into the NHS from UK training institutions; and (3) recruitment of doctors and nurses into the NHS from international sources. The first strategy relied on improving the salaries, benefits, and other terms of service of UK health professionals. Over www.thelancet.com Vol 367 April 29, 2006
the past 7 years the Department of Health has issued a series of press releases claiming considerable increases in health worker compensation.31 However, the real increase in the basic minimum salary for most grades of doctors and nurses averaged only 1·3% per year between 1997 and 2004. With the exceptions of the new consultant contract awarded in 2004, which increased minimum consultant pay by 21%, and a 6·3% increase awarded to grade D clinical nurses in 1999, no other increase amounted to more than 2% per year.32 Office of Manpower Economics data suggest that 9·2% of registered nurses left the NHS in the 2002–03 period and that 3800 nurses (1·3% of the stock) returned from overseas to the NHS. Both estimates have been stable over recent years suggesting no effect of pay increases on retention or return.33 Comparable statistics are not available with which to assess retention of physicians. The UK government’s second strategy for increasing staffing levels depends on increasing enrolment in schools of nursing and medicine. Between 1996/97 and 2003/04, the number of English nursing and midwifery training commissions increased by 62%,33 reversing the sharp decline of the first half of the 1990s in nursing graduates but only to the point that graduation rates had almost recovered to their 1992 levels by 2002. In 1998, the government also committed to increasing the number of medical students by 1000 (20% of the 1997 level) by 2005.34 In fact by 2002, the annual number of acceptances to medical school had increased by a third,35 four new medical schools were opened in 2002,36 and in 2003, medical school acceptance was 50% higher than in 1997.19 These increases are yet to affect the number of medical graduates, however. A surge in international recruitment of nurses began around 1998, with the number of international nursing graduates approaching the number of domestically produced nurses for the first time in 2001 (figure 1).37 By contrast, since the 1980s, international medical graduates (especially from outside the EU) have made up the majority of new medical registrations every year.38,39 In 2001, the NHS launched a global advertising campaign to attract foreign-trained consultants and general practitioners.40,41 By 2003, the number of newly registered physicians trained overseas doubled, whereas Physicians
Registered nurses
Density per 100 000 population
% of stock trained internationally
Density per 100 000 population
UK
16625*
3026
49725*
US
295
26
773
France
32925
326*
66725
NA
Germany
36225
624*
95125
NA
28
26
25
% of stock trained internationally 727 1329
*See text for qualifications. NA=not available
Table 1: Human resources for health by destination country
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INGs as % of new NMC registrants IMGs as % of new GMC registrants Sub-Saharan African nurses newly registered with NMC Sub-Saharan African physicians newly registered with GMC
4000
70
3500
60
3000
50
2500
40
2000
30
1500
20
1000
10
500 0
95 19 96 19 97 19 98 19 99 20 00 20 01 20 02 20 03
94
19
19
93
92
19
19
19
91
90
0
19
Number of African physicians and nurses registering for the first time
Foreign trained health workers as % of all new registrants
80
Figure 1: International medical graduates (IMGs) and international nursing graduates (INGs) registering for the first time in the UK, 1990–2003 Sources: Registration statistics of the Nursing and Midwifery Council23 and General Medical Council (Holt M, General Medical Council, personal communication)20,21
the number educated in sub-Saharan Africa tripled (figure 1). (Holt M, General Medical Council, personal communication)38,42 Overall, the number of nurses working for the NHS went up by 48 800 (about 20%) between 1997 and 2003. 73% of this increase was achieved through international recruitment.36 The effect on specific countries can be substantial. From 1998 to 2003, the Nursing and Midwifery Council registered 8% of the total nursing workforces of Malawi and Ghana.25,37 The number of NHS physicians increased by 17 500 (roughly 21%).43 On the INGs as % of those passing NCLEX-RN IMGs as % of first year US residents Sub-Saharan African physicians newly licensed in the US Sub-Saharan African nurses passing the NCLEX-RN (estimated)
600 500
20
400 15 300 10 200 5
100
96 19 97 19 98 19 99 20 00 20 01 20 02 20 03
19
95
19
94
19
93
92
19
19
19
91
0
90
0
19
Numbers of African physicians beginning work/nurses qualifying
Foreign trained health workers as % of those beginning work or qualifying
25
Figure 2: International medical graduates (IMGs) starting work and international nursing graduates (INGs) qualifying in the US, 1990–2003 Sources: National Council of State Boards of Nursing (NCSBN) for national licensure examination for registered nurses (NCLEX-RN) statistics21; Cooper19 for estimates of IMGs as a percentage of first-year medical residents. AMA Physician Masterfile for statistics on year of first licensure.20
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assumption that physician retention and return did not change, the statistics suggest that 80% of the growth in the NHS physician workforce can be attributed to international recruitment.37,38 More than half the increase in doctors was achieved in the 2 years following the launch of the global recruitment campaign. Of the additional overseas-trained physicians registered during 2002 and 2003, 24% came from sub-Saharan Africa. In the USA, a freeze on enrolment in medical schools resulted from a series of official medical workforce assessments, the first of which was released in 1980.44,45 The number of graduates has held constant at roughly 17 000 per year from 1982 to 2005. Over this period the US population grew by 27%. The number of doctors entering postgraduate training was also stagnant from 1980 to 1989, but then rose by 20% over the following 8 years as a result of increasing numbers of international medical graduates.19,46 From the late 1980s onwards, the federal Medicare programme subsidised residency training to an amount estimated to exceed its costs. By 1997, residency programmes were receiving US$6·8 billion per year from the federal government and additional funds from state governments. This financial backing has been seen as the fuel for the growth in postgraduate training. Greater than 60% of the growth in the number of residents (those in postgraduate medical training) between 1988 and 1993 can be attributed to increases in the numbers of international medical graduates from 14% to 23% of all residents (figure 2).19–21,47 The percentage of all active US doctors who were initially trained overseas has grown from 17% in 1970 to 26% in 2002. Notably, however, a growing percentage of international medical graduates (rising from 10% in 1994 to 32% in 2000) are US citizens who have gone abroad to study when they could not get places in US medical schools.48,49 In the past 5–7 years, total resident numbers stagnated and then declined. This fall in numbers followed a major policy decision taken by the US Congress in 1997 as part of the Balanced Budget Act.50 This act specified that enrolment in residency programmes was to be frozen at the level of 1996, putting a halt to further growth in postgraduate medical training. Between 1999 and 2001, international medical graduate numbers seem to have declined by 22% (figure 2).10,19 The past 15 years have seen striking swings in the actual and projected demand for registered nurses in the USA. Registered nurses’ wages fell or stagnated between 1990 and 1997, increasing by 0·3% per annum 1990–94, and falling by 1·5% per annum 1994–97.10,51 The number of nursing school graduates, which had previously been growing steadily, began to fall after 1995. There were 26% fewer graduates in 2000 than in 1995.10 Newly entering international nursing graduates also declined in absolute numbers and as a percentage of all nurses qualifying through the national licensure examination for registered nurses (figure 2).21 These trends have been explained by the growth of managed www.thelancet.com Vol 367 April 29, 2006
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care arrangements that tended to reduce the growth in hospital positions for registered nurses.51,52 However, the move towards managed care faltered in the late 1990s, and from 1998 to 2002 growth in these positions resumed.29,53 Major personnel shortages in the USA were widely predicted by the late 1990s10,49 Registered nurses’ real wages grew by 5% in 2001/02, and by 1·8% in 2002/03; hospitals increased their employment of nurses by 185 000 in these 2 years and employment of non-hospital registered nurses increased by 22 000. Overall employment of nurses grew by 10% between 2001 and 2003;29,53 an influx of 66 039 foreign-born nurses into the labour market during this period (figure 2) accounted for 32% of this increase. From 1994 to 2002, the numbers of foreignborn nurses increased by 71% and the proportion of all those registered in the USA but born overseas increased from 9% in 1994 to 13% in 2002. Between 1960 and 1997, the doctor density ratio increased from 100 to 330 per 100 000 population in France.54 During this escalation, in 1971, a numerus clausus (quota) policy was introduced, limiting the number of students who could advance from first to second year of medical school. By the end of the 1970s, the number of graduates from medical schools began to fall as the quota was progressively reduced from about 8500 to about 3700 per year.23 The rate of growth in numbers of French doctors dropped from an average of about 4·6% per year in the 1980s to about 1·6% per year in the 1990s. Thus, France’s physician density was predicted to actually decline by 24% by 2020. Until the late 1990s, there was consensus that there was an over supply of doctors and hence there was support for these trends. More recently, shortages in some regions and specialties have been described55–58 and the Rapport Berland, a health workforce analysis commissioned by the French Ministry of Health, drew attention to regional disparities and the extent to which continuation with the current policy would result in falling doctor densities.18 Acting on such concerns, French health and education authorities have steadily increased the numerus clausus from 3850 in 1998 to 6200 in 2005 and seem to have accepted the recommendation to increase further to 8000 by 2008.59,60 Over the past 7 years, health authorities have also relaxed restrictions on the numbers of foreign-educated doctors who receive official permission to practise in France. France has historically granted full working privileges to most doctors trained in other European countries but has strictly limited the numbers of doctors trained outside the European Union.18,22 In 2001, at most, 4% of doctors practising in France had received their diplomas outside the European Union18 and 1·25% were educated in other European Union countries.22 Of non-European trained doctors, a substantial proportion have not been granted full working privileges, work under uncertain and constrained conditions, and may not figure in official statistics.22 The little information www.thelancet.com Vol 367 April 29, 2006
that is available, however, shows that there has been a substantial increase since 1997 in the number of nonEuropean-trained doctors who have been granted full working privileges. From 1993 to 1997, the number of such doctors was limited by a quota of 40–100 per year,22 but between 1997 and 2002, the number increased to an average of more than 700 per year.18 Non-Europeantrained doctors accounted for 25% of all doctors newly registered in 2000. Many of these have been drawn from the reservoir of those already in France who had not been granted full working privileges.18,22 Thus, to what extent—if any—there has been an increase in immigration is unknown. In 2000, health authorities increased the quota for nurses entering nursing schools by about a third, but this will not definitely result in increases in enrolment because schools do not always fill their quotas.61 Whether nursing schools will attract and retain sufficient numbers of qualified students may largely depend on the incentives offered to nurses. Between 1991 and 1998, self-employed nurses (who are the majority ambulatory nursing care providers) earned half as much as selfemployed general practitioners, and during this period the real earnings of general practitioners rose by 6% whereas those of nurses fell by 7%. Although selfemployed nurses form only about 15% of the total nursing workforce, their incomes, constrained by publicly regulated fee levels, probably relate to those of salaried nurses, as is the case for doctors in France. All nurses educated outside Europe are required to repeat at least the third and final year of nursing education in France18 and hence official statistics show all nurses to have been trained in France. In 2003 there were 5611 nurses (1·3% of the stock) working in France who were not French citizens, but this number underestimates the number of foreign-educated nurses, since a large percentage of foreign-educated health professionals, including two–thirds of all non-European educated doctors,22 have become French citizens. Data for trends in the demand and supply of German nurses are scarce because there is no central government or professional agency that compiles such statistics.60 We therefore focus on German doctors. Both the German Democratic Republic and the Federal Republic of Germany reported high doctor densities in comparison with other European countries. During the 1990s, the federal government transferred over DM100 billion per year to develop and raise the living standards of those in the east and the two health care systems converged rapidly in terms of infrastructure and spending patterns. Cost containment measures seem to have had considerable effects on the German labour market. Although doctors’ real earnings increased by more than 10% between 1985 and 1992, they have since stagnated.62–64 Tightening of hospital and health insurance budgets is argued to have led to an increase in the rate of 1451
Public Health
Demand
Domestic supply
Price
Migration
Policy instruments
Level of public expenditure on health Regulation of content of insurance coverage
Subsidy levels in training (eg, publicly funded places) Quotas Entry requirement to professions
Regulation of prices, wages, and fee levels
Migration controls Entry requirements to professions
Market forces
Private expenditure on health and health insurance
Private investment in training Take-up of available subsidised training places
Price allowed to reflect market conditions
Supply response to vacancy rates, earning potential and effectiveness of migration controls of health workers outside the domestic market
In unregulated markets, demand and supply are brought to the same level by the movement of price. Where demand, domestic supply and price are constrained from interacting in this way by regulation, migration can correct for a shortage of domestic supply. If in-migration at the expense of the poorest countries is to be avoided, domestic demand and supply need to be brought into equilibrium. Where demand, domestic supply, and price are effectively regulated, the policy instruments that control these variables can be used to achieve that.
Table 2: Schematic illustration of some factors involved in producing migration outcomes in health labour market
unemployment among doctors from 2% in 1990 to a peak of 2·7% in 1997.65 The numbers of students enrolling in and graduating from medical school dropped by 25% each between 1994 and 2001. The number of medical graduates who decided not to begin postgraduate medical training increased by 37% over the same period.66 However, the post-reunification reforms are now perceived to have resulted in shortages of doctors in parts of Germany, and unemployment dropped to 1·5%, which is its lowest level since 1985 in 2003.65 Foreign doctors working in Germany increased by 36% between 1995 and 2003. About 60% of this influx came from countries to the east and southeast of Germany (especially Russia, Poland, Ukraine, and Turkey). Between 1997 and 2003 the number of doctors working in Germany who are citizens of sub-Saharan African countries increased by only 100, 15% more than the number in 1997.67
Discussion and conclusions The evidence from the four countries elucidates the balance between the effect of market forces and policy in determining the state of OECD countries’ labour markets. Market forces clearly have an important role. As one example, the markets for doctors in Germany and for nurses in the USA demonstrate the effect of periods of pay depression in falling recruitment to training schools and retention of trained staff in the sector. To the extent that market forces hold sway, policies have to consider unintended as well as intended implications. A particular complication in health labour markets is the lagged nature of supply responses. A decision to train more doctors today affects the supply of doctors 6 or more years later. The lag for nurses is at least 3 years. Lagged market models have particular characteristics: they are less likely to have achieved equilibrium at any specific time and can operate in unstable cobweb-type patterns of market behaviour. These patterns result in pendulum swings from shortage to surplus,68 and some of the country accounts are suggestive of such market behaviour, showing rapid swings in pay and employment levels. However, what is striking is that major changes to labour market conditions are almost always the result of 1452
changing perspectives among those determining health sector policy and consequent policy initiatives and change. In the UK, the change to a Labour Party government in 1997 resulted in a sharp increase in the rate of growth of health expenditure and consequent demand for qualified health staff. Despite recognition of the need to increase pay and retention to support plans for health labour force expansion, commitments to substantial improvement in this area were partly or wholly unfulfilled, especially for nurses. This failure created disequilibrium in the national health labour market that was not corrected by price (wage) adjustment but instead by sourcing additional staff from overseas. In the USA, enthusiasm for managed care approaches depressed the market for nurses during most of the 1990s, and the waning of that enthusiasm marked a turning point after which nurse employment grew by 10% in 2 years. More than 66 000 foreign-born nurses joined the US health sector in that same 2-year period. In France, there was an about change in policy-makers’ perception of whether the health sector was over or under staffed. This switch produced pronounced shifts in training policy and concomitant relaxation of the rules for entry to France’s health labour markets. In Germany, health workforce trends have been shaken by the vast political project of reunification, which resulted first in a perceived need for strong cost containment measures that controlled doctors’ earnings, then in perceived doctor shortage that has been accompanied by increased medical immigration. The message from this analysis is that we are not at the mercy of market forces (table 2). Policies have driven demand for health workers that has outstripped national supply over at least some period in all four countries, and policies can intervene to reduce the degree of inmigration of health workers from low-income countries. To avoid exploitation of the training expenditures of poorer countries, at national level in higher-income countries we need, importantly, to bring into balance (1) demand that is ever increasing (as a result of the familiar forces of growing economies, expanding technologies, and ageing populations) but is also highly responsive to public expenditure plans, cost containment policy, and political www.thelancet.com Vol 367 April 29, 2006
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support for health care delivery models such as managed care; (2) numbers in training—almost wholly a policy variable in all four countries except when training quotas or their equivalents are not filled—and (3) pay and employment conditions, which in countries such as the UK are largely determined by policymakers and in countries such as the USA, where private sector employment dominates, are largely market–determined. The highly regulated French and German systems represent intermediate points. The policy implications for sectors dominated by public employment are thus clearer. In the UK, increasing nursing pay would seem to make the single largest contribution to resolving the labour market imbalance that is draining poor countries of their health staff. In the USA, ensuring that numbers graduating from medical and nursing schools keep up with expanding demands will reduce incentives for postgraduate training programmes and hospitals (for example) to seek to source lower paid health staff from elsewhere. It may also serve to moderate remuneration. As long as earnings in the USA remain among the highest in the world and high compared with other similarly skilled occupations there for both doctors and nurses, there are fewer risks of local retention and recruitment problems that would undermine that strategy in the long run. In balancing these factors at national level, policy seems to need a better understanding of the lagged nature of health labour markets, to avoid the pendulum swings in conditions that seem to have affected some countries. At present, the accounts of trends in each country suggest little sign that any is heading towards a local equilibrium. Nevertheless, the situation looks especially acute for nursing markets. Access to the services of trained nurses in low-income countries is likely to be under sustained pressure in the immediate future. There has been justifiable pressure on the UK to respond to the implications of its policies for human resource availability in the poorest countries.3,69,70 The small amount of analysis up to now comparing the volume of health worker flows suggests that the UK benefits more than other high-income countries from health worker emigration from the poorest countries.9 Putting aside questions of moral responsibility, other countries too control policy levers that ultimately affect the outcome. Although sub-Saharan Africa might not be the dominant origin of the influx of foreign-born nurses to the USA, that country’s health labour market is likely to be an important driver of what has been called the medical carousel,71 a singularly inappropriate metaphor in view of the absence of cyclical characteristics of the pattern, or happy result. The so-called carousel might instead be viewed as a hierarchy of inter-related labour markets, with countries such as the USA sitting near the top of that hierarchy and attracting immigrant health staff from lower-income countries, which in turn fill the www.thelancet.com Vol 367 April 29, 2006
gap with migrants from still lower-income countries. The matching of local training levels, demand, and pay and other working conditions in any country further up the hierarchy will ameliorate the exodus from lowestincome countries. The statistics presented for the UK demonstrate the small success so far of efforts to moderate the effect of health worker migration through a recruitment code introduced in 2001.72 Time will tell whether recent modifications to this code73 render it more effective. Even if such codes prove to be weak ways of controlling labour migration, other policies related to work permits, visas, and licensing seem to increase the costs of immigration and constrain health-worker flows from low-income countries. Such policies have until recently restricted non-EU health worker migration to France and they may be a leading constraint to immigration of health workers from low-income countries to the USA.74 Although not strictly comparable, figures 1 and 2 suggest that the numbers of health workers migrating from sub-Saharan Africa to the UK have recently been an order of magnitude greater than the numbers migrating to the USA. Confronted with labour shortages or lobbying from the health care industry, however, policymakers in various OECD countries have shown a willingness to ease immigration, licensing requirements, or both, for internationally trained health workers.18,75 Language is likely to provide some of the explanation as to why Anglophone countries are most affected by the out-migration problem. These accounts suggest that France and Germany may become more accessible destinations in the near future, raising concerns in particular for the countries of francophone Africa. Outmigration of doctors from the countries of Eastern Europe to Germany that has accelerated in recent years poses fewer immediate difficulties since it is widely accepted that these countries have long been over-medicalised.76 Conflict of interest statement We declare that we have no conflict of interest. Acknowledgments Background research for this investigation received financial support from the UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR), study A41327. McPake is Programme Head of the Health Systems Development Programme which is funded by the UK Department for International Development. The funding source for this work made no contribution to the study design, collection, analysis or interpretation of data. References 1 Sagoe K. Using the diaspora to strengthen health workforce capacity, presentation at the International Organization for Migration seminar on health and migration, Geneva, June 9–11, 2004. http://www.iom.int/documents/officialtxt/en/ pp%5Fdiaspora%5Fsakoe.pdf (accessed Dec 13, 2005). 2 Dovlo D, Nyonator F. Migration by graduates of the university of ghana medical school: a prelminary rapid appraisal. Hum Res Health Dev J 1999; 3: 34–37. 3 Mensah K, Mackintosh M, Henry L. The ‘skills drain’ of health professionals from the developing world: a framework for policy formulation. Medact, 2005. http://www.medact.org/content/ Skills%20drain/Mensah%20et%20al.%202005.pdf (accessed Dec 13, 2005).
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4
5
6
7
8 9 10
11
12 13
14
15 16 17
18
19
20
21
22
23
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Dumont JC, Meyer JB. The international mobility of health professionals: an evaluation and analysis based on the case of South Africa. In: Trends in International Migration 2003. Organisation for economic cooperation and development, 2004. http://www.queensu.ca/samp/migrationresources/braindrain/ documents/oecd.pdf (accessed Dec 13, 2005). Bailey T. Skills migration. In: Human Resources Development Review 2003. Pretoria: Human Sciences Research Centre of South Africa, 2004: 234–55. http://hrdwarehouse.hsrc.ac.za/hrd/ skillsmigration/skillsmigration.pdf (accessed Dec 13, 2005). Hall E, Erasmus J. Medical practitioners and nurses. In: Human Resources Development Review 2003. Pretoria: Human Sciences Research Council of South Africa, 2004: 522–53. http://hrdware house.hsrc.ac.za/hrd/doctorsnurses/doctorsnurses.pdf (accessed Dec 3, 2005). Grant H. From the Transvaal to the prairies: the migration of south african physicians to canada. Working Paper no WP02–04 Prairie Centre of Excellence for Research on Immigration and Integration. http://www.queensu.ca/samp/migrationresources/ braindrain/documents/grant.pdf (accessed Dec 13, 2005). Diallo K. Data on the migration of health-care workers: sources, uses and challenges. Bull World Health Organ 2004; 82: 601–07. Buchan J, Parkin T, Sochalski J. International nurse mobility: trends and policy implications. Geneva: World Health Organization, 2003. US Department of Health and Human Services, Health Resources and Services Administration. Projected supply, demand, and shortages of registered nurses: 2000–2020. ftp://ftp.hrsa.gov/ bhpr/nationalcenter/rnproject.pdf (accessed Dec 13, 2005). Cooper R, Getzen TE, McKee H, Laud P. Economic and demographic trends signal an impending physician shortage. Health Aff 2002; 21: 222–31. Buchan J. Global nursing shortages. BMJ 2002; 324: 751–52. Bach S. International migration of health workers: labour and social issues. Geneva: International Labour Office, 2003. http:// www.ilo. org/public/english/dialogue/sector/papers/health/wp209.pdf (accessed Dec 13, 2005). Liese B, Dussault G. The state of the health workforce in sub-Saharan Africa: evidence of crisis and analysis of contributing factors. Africa Regional Human Development Working Paper Series, 2004. http:// siteresources.worldbank.org/AFRICAEXT/Resources/No_75.pdf (accessed Dec 13, 2005). Joint Learning Initiative. Human resources for health: overcoming the crisis. Cambridge, MA, USA: Harvard University Press, 2004. Grumbach K. Fighting hand to hand over physician workforce policy. Health Policy 2002; 21: 13–27. Chan B. From perceived surplus to perceived shortage: what happened to Canada’s physician workforce in the 1990s? Ottawa, ON, Canada: Canadian Institute for Health Information, 2002. Berland Y. Demographie des professions de sante (“Rapport Berland”). 2002, A workforce analysis commissioned by le Ministre de la Santé, de la Famille et des Personnes Handicapées. http:// lesrapports.ladocumentationfrancaise.fr/cgi-bin/brp/telestats. cgi?brp_ref=024000643&brp_file=0000.pdf (accessed Dec 13, 2005). Cooper R. What can be done about the doctor shortage? Presentation to the Program Directors of the Council of Medical Specialty Societies, Chicago, 2004. http://www.cmss.org/images/ Cooper’s_Manpower_Study2.ppt (accessed Dec 13, 2005). Medical Marketing Services. Background information of the AMA Physician Masterfile. http://www.mmslists.com/main.asp (accessed Dec 13, 2005). National Council of State Boards of Nursing. Nurse Licensure and NCLEX Examination Statistics,1983–2004. http://www.ncsbn.org/ testing/psychometrics_nclexlicensure_examstats.asp (accessed Dec 13, 2005). Couffinhal A, Mousquès J. Les médecins diplômés hors de France: statuts et caractéristiques. Questions d’économie de la santé 2001; 45: 1–6. http://www.irdes.fr/Publications/Bulletins/QuestEco/ pdf/ qesnum44.pdf (accessed Dec 13, 2005). Couffinhal A, Mousquès J. La démographie médicale française: état des lieux. 2001, Questions d’économie de la santé 2001; 44: 1–6. http:// www.irdes.fr/Publications/Bulletins/QuestEco/pdf/qesnum44.pdf (accessed Dec 13, 2005). BAK. Ärztestatistik. 1998–2004, Bundesärztekammer. http://www. bundesaerztekammer.de/30/Aerztestatistik/index.html (accessed Dec 13, 2005).
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Global Atlas of the Health Workforce—Basic data (various years; last updated Sept 28, 2004). http://www.who.int/globalatlas/data Query/default.asp (select Basic data as topic, All nurses density and Physicians density items, country, and Latest available data; accessed Dec 13, 2005). Forcier M, Simoens S, Giuffrida A. Impact, regulation and health policy implications of physician migration in OECD countries. Hum Resour Health 2004; 2: 12. Buchan J. International rescue? The dynamics and policy implications of the international recruitment of nurses to the UK. J Health Serv Res Policy 2004; 9 (suppl 1): 10–16. AMA. Physician characteristics and distribution in the US. Chicago: American Medical Association, 2004. Buerhaus P, Staiger D, Auerbach D. Trends: is the current shortage of hospital nurses ending? Health Aff 2003; 22: 191–98. UK Department of Health. The NHS Plan: a plan for investment. A plan for reform. http://www.dh.gov.uk/assetRoot/04/05/57/83/ 04055783.pdf (accessed Dec 13, 2005). UK Department of Health. Biggest nursing pay rise for 10 years— paid in full, 1999. http://www.dh.gov.uk/PublicationsAnd Statistics/PressReleases/PressReleasesNotices/fs/en?CONTENT_ ID=4025294&chk=X4L%2BPn (accessed Dec 13, 2005). UK Department of Health. Advance letters from 1995 to 2004. http:// www.dh.gov.uk/PublicationsAndStatistics/LettersAndCirculars/ AdvancedLetters/fs/en (accessed Dec 3, 2005). Buchan J, Seccombe I. RCN Labour market review: fragile future? A review of the UK nursing labour market in 2003. London: Royal College of Nursing, 2003. Medical student numbers boosted. British Broadcasting Corporation, 1998. http://news.bbc.co.uk/1/hi/health/137506.stm (accessed Dec 13, 2005). UK University and Colleges Admissions Service. Applicants and accepts for pre-clinical medicine studies. http://search1.ucas.co.uk/ fandf00/index.html (accessed Dec 3, 2005; select UK, specific year, subject line (JACS), and Pre-Clinical Medicine [A1]). GMC Annual Review, 2002. London: General Medical Council, 2002. NMC. Statistical analysis of the register, 1 April 2003 to 31 March 2004. Nursing & Midwifery Council, 2004. (Table 1 and Table 13 for admission statistics, by country from 1998–99 to 2003–2004) http:// www.nmc-uk.org/(52izdi55i51yhcztsodxec45)/aFrameDisplay. aspx?DocumentID=602 (accessed Dec 13, 2005). GMC. Annual report and accounts, 2002. http://www.gmc-uk.org/ publications/annual_reports/review_archive/report2003.pdf (accessed Dec 13, 2005). GMC. Annual review 2004/2005. http://www.gmc-uk.org/ publications/annual_reports/annual_review_2004_5.pdf (accessed Dec 13, 2005). UK Department of Health. International recruitment of consultants and general practitioners for the NHS in England. http://www.dh.gov. uk/assetRoot/04/06/71/45/04067145.pdf (accessed Dec 13, 2005). British Broadcasting Coporation. The NHS and overseas doctors: an iCan briefing. http://www.bbc.co.uk/dna/ican/A2979165 (accessed Dec 13, 2005). GMC. Annual Review 2003/4: qualified to practise. London: General Medical Council, 2004. UK Department of Health. All staff in the NHS: 1994 to 2004—HCHS and General Practice workforce (FTE round spreadsheet). http:// www.dh.gov.uk/assetRoot/04/10/65/95/04106595.xls (accessed Dec 13, 2005) Peterson SE, Rodin AE. GMENAC report on US physician manpower policies: recommendations and reactions. Health Policy Educ 1983; 3: 337–49. Council on Graduate Medical Education. 2002 summary report to the US Congress and the Secretary Department of Health and Human Services. http://www.cogme.gov/2002summary.pdf (accessed Dec 13, 2005). AAMC Data Book 2004. Washington, DC: Association of American Medical Colleges, 2004 Medicare and graduate medical education. 1995, Congressional Budget Office. http://www.cbo.gov/ftpdoc.cfm?index=17&type=1 (accessed Dec 13, 2005). National Residency Match Program. Advance data tables for the 2004 Residency Match. http://www.savethematch.org/pdf/ 2004Advdata.pdf (accessed Dec 13, 2005).
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Whelan G. The role of graduates of foreign medical schools (FMGS) in the internal medicine applicant pool. ECFMG presentation to the USA Association of Program Directors in Internal Medicine, April 12, 2000. http://www.im.org/AAIM/Meetings/PastMeetings/2000/ APDIM/whelan.pdf (accessed Dec 13, 2005). Council on Graduate Medical Education. The effects of the balanced budget act of 1997 on graduate medical education, 2000. http:// www.cogme.gov/resource_bba3.htm (accessed Dec 13, 2005). Buerhaus P, Staiger D. Trouble in the nurse labor market? Health Aff 1999; 18: 214–22. Schumacher E. The earnings and employment of nurses in an era of cost containment. http://www.ecu.edu/econ/wp/98/ecu9803.pdf (accessed Dec 13, 2005). Buerhaus P, Needleman J, Mattke S, Stewart M. Strengthening hospital nursing. Health Aff 2002; 21: 123–32. Buerhaus P, Staiger D, Auerbach D. New signs of a strengthening US nurse labor market? Health Aff 2004; published online Nov 17. DOI: 10.1377/hlthaff.var.526. Sandier S, Paris V, Polton D. Health care systems in transition: France. http://www.euro.who.int/document/e83126.pdf (accessed Dec 13, 2005). Langlois J. La demographie medicale future: mesures proposées par l’Ordre des médecins. Paris: Conseil National de l’Ordre des Médecins, 2001. Langlois J. Démographie médicale: nous payons l’absence de prévision! Le Bulletin de l’Ordre des Médecins 2003; 15: 1. http:// bulletin.conseil-national.medecin.fr/CNOM/bulletin.nsf/ (html)/315BOMN315P03A1?OpenDocument (accessed Dec 3, 2005). Dupilet C. Démographie médicale: pénurie de médecins annoncée. Medcost, 2000. http://www.medcost.fr/html/ economie_sante_eco/eco_271200.htm (accessed Dec 13, 2005). Mattei JF. Augmentation du numerus clausus et organisation de l’offre de soins. http://www.sante.gouv.fr/htm/actu/ 31_031023.htm (accessed Dec 3, 2005). Gattuso C. Le numerus clausus sera porté à 6 200 étudiants en 2005. Le Quotidien du Médecins, 2004. http://www.quotimed. com/journal/index.cfm?fuseaction=viewarticle&DartIdx=198098 (accessed Dec 13, 2005). Paris V. Perspectives démographiques des personnels non médicaux. http://www.irdes.fr/En_ligne/PowerPoint/profsan/ paramedic.pdf (accessed Dec 3, 2005). Busse R, Riesberg A. Health care systems in transition: Germany. http://www.euro.who.int/document/e68952.pdf (accessed Dec 13, 2005).
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Worz M, Busse R. Structural reforms for Germany’s health care system? Newsletter of the European Observatory on Health Care Systems 2002; 4. http://www.euro.who.int/Document/Obs/ EuroObserverWinter2002.pdf (accessed Dec 13, 2005). Schnee M, Brechtel T. Ärzte-Umfrage 1992 und 1998: Ärztinnen haben geringere Einkommen. Deutsches Arzteblatt 1999; 96: A30 93–96. http://aerzteblatt.lnsdata.de/pdf/96/48/a3093-6.pdf (accessed Dec 3, 2005). Abbildung 13: Anzahl der als arbeitslos gemeldeten Ärztinnen und Ärzte. Bundesärztekammer, 1996–2003. http://www.bundesaerzte kammer.de/30/Aerztestatistik/100Archiv/01Stat2003/PDF/ Abbildung13.pdf (accessed Dec 3, 2005) Gehen dem deutschen Gesundheitswesen die Ärzte aus? Berlin: Bundesärztekammer, 2002 (annex to 2002 annual statistical report). Abbildung 10: Entwicklung der Zahl der Neuzugänge an Ärzten im Praktikum bei den Ärztekammern. Bundesärztekammer, 2002. http://www.bundesaerztekammer.de/30/Aerztestatistik/100Archiv/ 02Stat2002/PDF/Abbildung10.pdf (accessed Dec 13, 2005). Samuelson P. Economics, an introductory analysis, 8th edn. NY, London, Sydney: McGraw Hill, 1970. Save the Children and Medact. Whose charity? Africa’s aid to the NHS. http://medact.org/content/Skills%20drain/ Whose%20charity%204%20page.pdf (accessed Dec 13, 2005). Buena de Mesquita J, Gordon M. The international migration of health workers: a human rights analysis. http://www.medact.org/ content/Skills%20drain/Bueno%20de%20Mesquita%20and%20 Gordon.pdf (accessed Dec 13, 2005). Bundred PE, Levitt C. Medical migration: who are the real losers? Lancet 2000; 356: 245–46. UK Department of Health. Code of practice for NHS employers involved in the international recruitment of healthcare professionals (2001 version). http://www.dh.gov.uk/assetRoot/ 04/03/46/51/04034651.pdf (accessed 13 Dec, 2004). UK Department of Health. Code of practice for NHS employers involved in the international recruitment of healthcare professionals (2004 revision). http://www.dh.gov.uk/assetRoot/ 04/09/77/34/04097734.pdf (accessed Dec 13, 2005). Aiken L, Buchan J, Sochalski J, Nichols B, Powell M. Trends in international nurse migration. Health Aff 2004; 23: 69–77. Organization for Economic Cooperation and Development. Trends in International Migration (SOPEMI), 2002. Paris: OECD, 2002. Healy J, McKee M. Implementing hospital reform in central and eastern Europe. Health Policy 2002; 61: 1–19.
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The health migration crisis: the role of four Organisation for Economic Cooperation and Development countries Bob Pond , Barbara McPake Lancet 2006; 367: 1448–55 Published Online March 21, 2006 DOI:10.1016/S01406736(06)68346-3 Avenue du Vieux Bourg 48, CH-1225 Chêne-Bourg, Switzerland (B Pond MD); and Institute for International Health and Development, Queen Margaret University College, Edinburgh EH12 8TS, UK (Prof B McPake PhD) Correspondence to: Prof Barbara McPake [email protected]
OECD The organisation for Economic Cooperation and Development is a group of 30 member countries that share a commitment to democratic government and market economy.
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The crisis of human resources for health that is affecting low-income countries and especially sub-Saharan Africa has been attributed, at least in part, to increasing rates of migration of qualified health staff to high-income countries. We describe the conditions in four Organisation for Economic Cooperation and Development (OECD) health labour markets that have led to increasing rates of immigration. Popular explanations of these trends include ageing populations, growing incomes, and feminisation of the health workforce. Although these explanations form part of the larger picture, analysis of the forces operating in the four countries suggests that specific policy measures largely unrelated to these factors have driven growing demand for health staff. On this basis we argue that specific policy measures are equally capable of reversing these trends and avoiding the exploitation of low-income countries’ scarce resources. These policies should seek to ensure local stability in health labour markets so that shortages of staff are not solved via the international brain drain. High rates of emigration from low-income and middleincome countries to those with higher incomes is one cause of a human resource crisis in health that is most acutely affecting the poorest parts of the lowest-income countries. Recent rises in such emigration have been documented for countries such as Ghana1–3 and South Africa,4–7 but incomplete and not fully comparable statistics have resulted in difficulty in analysing trends and comparing the parts played by most source and destination countries.8 Statistics for registration or qualification of nurses migrating to five countries show that since the mid 1990s there have been surges in the recruitment of overseas nurses to the UK and Ireland, less pronounced increases for the USA and Australia, and stable or falling levels for Norway.9 These recent rises in migration of health workers to some high-income countries indicate, in part, long-term demographic, economic, and workforce trends in Organisation for Economic Cooperation and Development (OECD) countries. In these countries, ageing populations and growing incomes feed the demand for health services whereas the ageing and feminisation of the health workforce combined with a rising preference for leisure time reduce the supply of health services.9–12 Hence some analysts point to the recent rise in immigration as evidence of major and enduring global shortages in nurses and doctors over the next decades.13–15 However, such long-term gradual trends cannot explain the abrupt surges in immigration of health workers to some countries, or why there is considerable variation between high-income countries in the levels and trends of immigration. Moreover, past projections of the supply and demand for health workers in several countries have proven that workforce prediction is a highly imperfect science.16–18 Analysis of the evolution of the current conditions in labour markets in OECD countries could provide insights and opportunities for policy to improve the global distribution of human resources. We review the evolution over recent decades of the supply and demand for physicians and nurses in four OECD
countries: the UK, the USA, France, and Germany. We look at key trends in the production, remuneration, and retention of health professionals as well as the factors that shape them. The aim is to provide a better understanding of migration of physicians and nurses from low-income countries. Physicians and nurses intending to work in the UK must first register with the General Medical Council and the Nursing and Midwifery Council, respectively, and each of these organisations keeps statistics on the country of education. Physicians have to complete a postgraduate residency training to practise in the USA. Cooper19 estimated levels and trends in number of international medical graduates by subtracting the number of medical school graduates from the number of physicians entering postgraduate training. Statistics on levels and trends in USA licensing of physicians from sub-Saharan Africa were extracted from the American Medical Association physician masterfile which records the date of first licensure and country of education of all physicians.20 For international medical graduates there is an average lag of 2 to 3 years between the time that they begin residency training and the time that they are first licensed. Rather than attempt to adjust for this lag, the unadjusted data are presented. International nursing graduates have to pass the national licensure examination for registered nurses before they are licensed in the USA, and statistics are available for their country of education.21 Statistics by country of education for the numbers passing this examination are available only for those taking the examination for the first time. Total passes of nurses trained in sub-Saharan Africa were estimated by assuming that the ratio of total passes to first-time passes was the same every year, as for all international nursing graduates taking the exam (range=1·4–1·6). The Conseil National de l’Ordre des Médecins22,23 and the Bundesärztekammer,24 the national medical associations of France and Germany, respectively, maintain rosters indicating the nationality of physicians with full working privileges. www.thelancet.com Vol 367 April 29, 2006
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Although these statistics on physician stocks are available for each year from 1998 to the present, they do not directly indicate the number of newly licensed health workers, and they underestimate the number of immigrant health workers because they show current nationality rather than country of education. Moreover, official French statistics omit a sizeable number of physicians trained outside the EU who work in French hospitals without full privileges. The French system allows few opportunities to practise in the public hospital system on a short-term contractual basis, and without the status of a fully medically qualified practitioner. The provisions have gradually broadened, and since 1999, include the possibility of authorisation to practise general medicine, but permission had been extended to very small numbers by 2001.22 The analysis of immigration of doctors to France is therefore based on the rough approximations made in an authoritative workforce projection document.18
Supply and demand for health workers in OECD countries Statistics from WHO’s Global human resources for health atlas25 suggest that the UK ranks among the least staffed of high-income countries, with 166 doctors and 497 nurses per 100 000 population (table 1)25–29—the second lowest doctor density (ahead of Turkey) and fourth lowest nurse density (ahead of Greece, Spain, and Turkey) of all OECD countries. However, this comparison seems to be misleading. Buchan27 reports that the official OECD figure for practising nurses counts only those working in the National Health Service (NHS) in England and Wales, although the UK population is used as the denominator. Approximately 270 000 nurses are counted, whereas if those working outside the NHS and in Scotland and Northern Ireland are included, the total would be about 390 000. This recalculation increases the nurse per 100 000 population ratio to approximately 650, ranking the UK closer to the middle of the European range. The election of the Labour government in the UK in 1997 was followed by a sharp rise in the rate of growth of expenditure on the NHS beginning in 1998. Government health officials set targets to substantially increase the number of nurses and doctors. For example, the number of nurses working for the NHS in England was set to increase by 20 000 (6%) between 1999 and 2004,30 and when this target was reached early, the government set a new target to increase nurses by 35 000 (10%), and general practitioners and consultants by 15 000 (25%) between 2001 and 2008. Several strategies were adopted to increase staffing: (1) retention of current staff and return of those working elsewhere; (2) recruitment of newly qualified health professionals into the NHS from UK training institutions; and (3) recruitment of doctors and nurses into the NHS from international sources. The first strategy relied on improving the salaries, benefits, and other terms of service of UK health professionals. Over www.thelancet.com Vol 367 April 29, 2006
the past 7 years the Department of Health has issued a series of press releases claiming considerable increases in health worker compensation.31 However, the real increase in the basic minimum salary for most grades of doctors and nurses averaged only 1·3% per year between 1997 and 2004. With the exceptions of the new consultant contract awarded in 2004, which increased minimum consultant pay by 21%, and a 6·3% increase awarded to grade D clinical nurses in 1999, no other increase amounted to more than 2% per year.32 Office of Manpower Economics data suggest that 9·2% of registered nurses left the NHS in the 2002–03 period and that 3800 nurses (1·3% of the stock) returned from overseas to the NHS. Both estimates have been stable over recent years suggesting no effect of pay increases on retention or return.33 Comparable statistics are not available with which to assess retention of physicians. The UK government’s second strategy for increasing staffing levels depends on increasing enrolment in schools of nursing and medicine. Between 1996/97 and 2003/04, the number of English nursing and midwifery training commissions increased by 62%,33 reversing the sharp decline of the first half of the 1990s in nursing graduates but only to the point that graduation rates had almost recovered to their 1992 levels by 2002. In 1998, the government also committed to increasing the number of medical students by 1000 (20% of the 1997 level) by 2005.34 In fact by 2002, the annual number of acceptances to medical school had increased by a third,35 four new medical schools were opened in 2002,36 and in 2003, medical school acceptance was 50% higher than in 1997.19 These increases are yet to affect the number of medical graduates, however. A surge in international recruitment of nurses began around 1998, with the number of international nursing graduates approaching the number of domestically produced nurses for the first time in 2001 (figure 1).37 By contrast, since the 1980s, international medical graduates (especially from outside the EU) have made up the majority of new medical registrations every year.38,39 In 2001, the NHS launched a global advertising campaign to attract foreign-trained consultants and general practitioners.40,41 By 2003, the number of newly registered physicians trained overseas doubled, whereas Physicians
Registered nurses
Density per 100 000 population
% of stock trained internationally
Density per 100 000 population
UK
16625*
3026
49725*
US
295
26
773
France
32925
326*
66725
NA
Germany
36225
624*
95125
NA
28
26
25
% of stock trained internationally 727 1329
*See text for qualifications. NA=not available
Table 1: Human resources for health by destination country
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INGs as % of new NMC registrants IMGs as % of new GMC registrants Sub-Saharan African nurses newly registered with NMC Sub-Saharan African physicians newly registered with GMC
4000
70
3500
60
3000
50
2500
40
2000
30
1500
20
1000
10
500 0
95 19 96 19 97 19 98 19 99 20 00 20 01 20 02 20 03
94
19
19
93
92
19
19
19
91
90
0
19
Number of African physicians and nurses registering for the first time
Foreign trained health workers as % of all new registrants
80
Figure 1: International medical graduates (IMGs) and international nursing graduates (INGs) registering for the first time in the UK, 1990–2003 Sources: Registration statistics of the Nursing and Midwifery Council23 and General Medical Council (Holt M, General Medical Council, personal communication)20,21
the number educated in sub-Saharan Africa tripled (figure 1). (Holt M, General Medical Council, personal communication)38,42 Overall, the number of nurses working for the NHS went up by 48 800 (about 20%) between 1997 and 2003. 73% of this increase was achieved through international recruitment.36 The effect on specific countries can be substantial. From 1998 to 2003, the Nursing and Midwifery Council registered 8% of the total nursing workforces of Malawi and Ghana.25,37 The number of NHS physicians increased by 17 500 (roughly 21%).43 On the INGs as % of those passing NCLEX-RN IMGs as % of first year US residents Sub-Saharan African physicians newly licensed in the US Sub-Saharan African nurses passing the NCLEX-RN (estimated)
600 500
20
400 15 300 10 200 5
100
96 19 97 19 98 19 99 20 00 20 01 20 02 20 03
19
95
19
94
19
93
92
19
19
19
91
0
90
0
19
Numbers of African physicians beginning work/nurses qualifying
Foreign trained health workers as % of those beginning work or qualifying
25
Figure 2: International medical graduates (IMGs) starting work and international nursing graduates (INGs) qualifying in the US, 1990–2003 Sources: National Council of State Boards of Nursing (NCSBN) for national licensure examination for registered nurses (NCLEX-RN) statistics21; Cooper19 for estimates of IMGs as a percentage of first-year medical residents. AMA Physician Masterfile for statistics on year of first licensure.20
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assumption that physician retention and return did not change, the statistics suggest that 80% of the growth in the NHS physician workforce can be attributed to international recruitment.37,38 More than half the increase in doctors was achieved in the 2 years following the launch of the global recruitment campaign. Of the additional overseas-trained physicians registered during 2002 and 2003, 24% came from sub-Saharan Africa. In the USA, a freeze on enrolment in medical schools resulted from a series of official medical workforce assessments, the first of which was released in 1980.44,45 The number of graduates has held constant at roughly 17 000 per year from 1982 to 2005. Over this period the US population grew by 27%. The number of doctors entering postgraduate training was also stagnant from 1980 to 1989, but then rose by 20% over the following 8 years as a result of increasing numbers of international medical graduates.19,46 From the late 1980s onwards, the federal Medicare programme subsidised residency training to an amount estimated to exceed its costs. By 1997, residency programmes were receiving US$6·8 billion per year from the federal government and additional funds from state governments. This financial backing has been seen as the fuel for the growth in postgraduate training. Greater than 60% of the growth in the number of residents (those in postgraduate medical training) between 1988 and 1993 can be attributed to increases in the numbers of international medical graduates from 14% to 23% of all residents (figure 2).19–21,47 The percentage of all active US doctors who were initially trained overseas has grown from 17% in 1970 to 26% in 2002. Notably, however, a growing percentage of international medical graduates (rising from 10% in 1994 to 32% in 2000) are US citizens who have gone abroad to study when they could not get places in US medical schools.48,49 In the past 5–7 years, total resident numbers stagnated and then declined. This fall in numbers followed a major policy decision taken by the US Congress in 1997 as part of the Balanced Budget Act.50 This act specified that enrolment in residency programmes was to be frozen at the level of 1996, putting a halt to further growth in postgraduate medical training. Between 1999 and 2001, international medical graduate numbers seem to have declined by 22% (figure 2).10,19 The past 15 years have seen striking swings in the actual and projected demand for registered nurses in the USA. Registered nurses’ wages fell or stagnated between 1990 and 1997, increasing by 0·3% per annum 1990–94, and falling by 1·5% per annum 1994–97.10,51 The number of nursing school graduates, which had previously been growing steadily, began to fall after 1995. There were 26% fewer graduates in 2000 than in 1995.10 Newly entering international nursing graduates also declined in absolute numbers and as a percentage of all nurses qualifying through the national licensure examination for registered nurses (figure 2).21 These trends have been explained by the growth of managed www.thelancet.com Vol 367 April 29, 2006
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care arrangements that tended to reduce the growth in hospital positions for registered nurses.51,52 However, the move towards managed care faltered in the late 1990s, and from 1998 to 2002 growth in these positions resumed.29,53 Major personnel shortages in the USA were widely predicted by the late 1990s10,49 Registered nurses’ real wages grew by 5% in 2001/02, and by 1·8% in 2002/03; hospitals increased their employment of nurses by 185 000 in these 2 years and employment of non-hospital registered nurses increased by 22 000. Overall employment of nurses grew by 10% between 2001 and 2003;29,53 an influx of 66 039 foreign-born nurses into the labour market during this period (figure 2) accounted for 32% of this increase. From 1994 to 2002, the numbers of foreignborn nurses increased by 71% and the proportion of all those registered in the USA but born overseas increased from 9% in 1994 to 13% in 2002. Between 1960 and 1997, the doctor density ratio increased from 100 to 330 per 100 000 population in France.54 During this escalation, in 1971, a numerus clausus (quota) policy was introduced, limiting the number of students who could advance from first to second year of medical school. By the end of the 1970s, the number of graduates from medical schools began to fall as the quota was progressively reduced from about 8500 to about 3700 per year.23 The rate of growth in numbers of French doctors dropped from an average of about 4·6% per year in the 1980s to about 1·6% per year in the 1990s. Thus, France’s physician density was predicted to actually decline by 24% by 2020. Until the late 1990s, there was consensus that there was an over supply of doctors and hence there was support for these trends. More recently, shortages in some regions and specialties have been described55–58 and the Rapport Berland, a health workforce analysis commissioned by the French Ministry of Health, drew attention to regional disparities and the extent to which continuation with the current policy would result in falling doctor densities.18 Acting on such concerns, French health and education authorities have steadily increased the numerus clausus from 3850 in 1998 to 6200 in 2005 and seem to have accepted the recommendation to increase further to 8000 by 2008.59,60 Over the past 7 years, health authorities have also relaxed restrictions on the numbers of foreign-educated doctors who receive official permission to practise in France. France has historically granted full working privileges to most doctors trained in other European countries but has strictly limited the numbers of doctors trained outside the European Union.18,22 In 2001, at most, 4% of doctors practising in France had received their diplomas outside the European Union18 and 1·25% were educated in other European Union countries.22 Of non-European trained doctors, a substantial proportion have not been granted full working privileges, work under uncertain and constrained conditions, and may not figure in official statistics.22 The little information www.thelancet.com Vol 367 April 29, 2006
that is available, however, shows that there has been a substantial increase since 1997 in the number of nonEuropean-trained doctors who have been granted full working privileges. From 1993 to 1997, the number of such doctors was limited by a quota of 40–100 per year,22 but between 1997 and 2002, the number increased to an average of more than 700 per year.18 Non-Europeantrained doctors accounted for 25% of all doctors newly registered in 2000. Many of these have been drawn from the reservoir of those already in France who had not been granted full working privileges.18,22 Thus, to what extent—if any—there has been an increase in immigration is unknown. In 2000, health authorities increased the quota for nurses entering nursing schools by about a third, but this will not definitely result in increases in enrolment because schools do not always fill their quotas.61 Whether nursing schools will attract and retain sufficient numbers of qualified students may largely depend on the incentives offered to nurses. Between 1991 and 1998, self-employed nurses (who are the majority ambulatory nursing care providers) earned half as much as selfemployed general practitioners, and during this period the real earnings of general practitioners rose by 6% whereas those of nurses fell by 7%. Although selfemployed nurses form only about 15% of the total nursing workforce, their incomes, constrained by publicly regulated fee levels, probably relate to those of salaried nurses, as is the case for doctors in France. All nurses educated outside Europe are required to repeat at least the third and final year of nursing education in France18 and hence official statistics show all nurses to have been trained in France. In 2003 there were 5611 nurses (1·3% of the stock) working in France who were not French citizens, but this number underestimates the number of foreign-educated nurses, since a large percentage of foreign-educated health professionals, including two–thirds of all non-European educated doctors,22 have become French citizens. Data for trends in the demand and supply of German nurses are scarce because there is no central government or professional agency that compiles such statistics.60 We therefore focus on German doctors. Both the German Democratic Republic and the Federal Republic of Germany reported high doctor densities in comparison with other European countries. During the 1990s, the federal government transferred over DM100 billion per year to develop and raise the living standards of those in the east and the two health care systems converged rapidly in terms of infrastructure and spending patterns. Cost containment measures seem to have had considerable effects on the German labour market. Although doctors’ real earnings increased by more than 10% between 1985 and 1992, they have since stagnated.62–64 Tightening of hospital and health insurance budgets is argued to have led to an increase in the rate of 1451
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Demand
Domestic supply
Price
Migration
Policy instruments
Level of public expenditure on health Regulation of content of insurance coverage
Subsidy levels in training (eg, publicly funded places) Quotas Entry requirement to professions
Regulation of prices, wages, and fee levels
Migration controls Entry requirements to professions
Market forces
Private expenditure on health and health insurance
Private investment in training Take-up of available subsidised training places
Price allowed to reflect market conditions
Supply response to vacancy rates, earning potential and effectiveness of migration controls of health workers outside the domestic market
In unregulated markets, demand and supply are brought to the same level by the movement of price. Where demand, domestic supply and price are constrained from interacting in this way by regulation, migration can correct for a shortage of domestic supply. If in-migration at the expense of the poorest countries is to be avoided, domestic demand and supply need to be brought into equilibrium. Where demand, domestic supply, and price are effectively regulated, the policy instruments that control these variables can be used to achieve that.
Table 2: Schematic illustration of some factors involved in producing migration outcomes in health labour market
unemployment among doctors from 2% in 1990 to a peak of 2·7% in 1997.65 The numbers of students enrolling in and graduating from medical school dropped by 25% each between 1994 and 2001. The number of medical graduates who decided not to begin postgraduate medical training increased by 37% over the same period.66 However, the post-reunification reforms are now perceived to have resulted in shortages of doctors in parts of Germany, and unemployment dropped to 1·5%, which is its lowest level since 1985 in 2003.65 Foreign doctors working in Germany increased by 36% between 1995 and 2003. About 60% of this influx came from countries to the east and southeast of Germany (especially Russia, Poland, Ukraine, and Turkey). Between 1997 and 2003 the number of doctors working in Germany who are citizens of sub-Saharan African countries increased by only 100, 15% more than the number in 1997.67
Discussion and conclusions The evidence from the four countries elucidates the balance between the effect of market forces and policy in determining the state of OECD countries’ labour markets. Market forces clearly have an important role. As one example, the markets for doctors in Germany and for nurses in the USA demonstrate the effect of periods of pay depression in falling recruitment to training schools and retention of trained staff in the sector. To the extent that market forces hold sway, policies have to consider unintended as well as intended implications. A particular complication in health labour markets is the lagged nature of supply responses. A decision to train more doctors today affects the supply of doctors 6 or more years later. The lag for nurses is at least 3 years. Lagged market models have particular characteristics: they are less likely to have achieved equilibrium at any specific time and can operate in unstable cobweb-type patterns of market behaviour. These patterns result in pendulum swings from shortage to surplus,68 and some of the country accounts are suggestive of such market behaviour, showing rapid swings in pay and employment levels. However, what is striking is that major changes to labour market conditions are almost always the result of 1452
changing perspectives among those determining health sector policy and consequent policy initiatives and change. In the UK, the change to a Labour Party government in 1997 resulted in a sharp increase in the rate of growth of health expenditure and consequent demand for qualified health staff. Despite recognition of the need to increase pay and retention to support plans for health labour force expansion, commitments to substantial improvement in this area were partly or wholly unfulfilled, especially for nurses. This failure created disequilibrium in the national health labour market that was not corrected by price (wage) adjustment but instead by sourcing additional staff from overseas. In the USA, enthusiasm for managed care approaches depressed the market for nurses during most of the 1990s, and the waning of that enthusiasm marked a turning point after which nurse employment grew by 10% in 2 years. More than 66 000 foreign-born nurses joined the US health sector in that same 2-year period. In France, there was an about change in policy-makers’ perception of whether the health sector was over or under staffed. This switch produced pronounced shifts in training policy and concomitant relaxation of the rules for entry to France’s health labour markets. In Germany, health workforce trends have been shaken by the vast political project of reunification, which resulted first in a perceived need for strong cost containment measures that controlled doctors’ earnings, then in perceived doctor shortage that has been accompanied by increased medical immigration. The message from this analysis is that we are not at the mercy of market forces (table 2). Policies have driven demand for health workers that has outstripped national supply over at least some period in all four countries, and policies can intervene to reduce the degree of inmigration of health workers from low-income countries. To avoid exploitation of the training expenditures of poorer countries, at national level in higher-income countries we need, importantly, to bring into balance (1) demand that is ever increasing (as a result of the familiar forces of growing economies, expanding technologies, and ageing populations) but is also highly responsive to public expenditure plans, cost containment policy, and political www.thelancet.com Vol 367 April 29, 2006
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support for health care delivery models such as managed care; (2) numbers in training—almost wholly a policy variable in all four countries except when training quotas or their equivalents are not filled—and (3) pay and employment conditions, which in countries such as the UK are largely determined by policymakers and in countries such as the USA, where private sector employment dominates, are largely market–determined. The highly regulated French and German systems represent intermediate points. The policy implications for sectors dominated by public employment are thus clearer. In the UK, increasing nursing pay would seem to make the single largest contribution to resolving the labour market imbalance that is draining poor countries of their health staff. In the USA, ensuring that numbers graduating from medical and nursing schools keep up with expanding demands will reduce incentives for postgraduate training programmes and hospitals (for example) to seek to source lower paid health staff from elsewhere. It may also serve to moderate remuneration. As long as earnings in the USA remain among the highest in the world and high compared with other similarly skilled occupations there for both doctors and nurses, there are fewer risks of local retention and recruitment problems that would undermine that strategy in the long run. In balancing these factors at national level, policy seems to need a better understanding of the lagged nature of health labour markets, to avoid the pendulum swings in conditions that seem to have affected some countries. At present, the accounts of trends in each country suggest little sign that any is heading towards a local equilibrium. Nevertheless, the situation looks especially acute for nursing markets. Access to the services of trained nurses in low-income countries is likely to be under sustained pressure in the immediate future. There has been justifiable pressure on the UK to respond to the implications of its policies for human resource availability in the poorest countries.3,69,70 The small amount of analysis up to now comparing the volume of health worker flows suggests that the UK benefits more than other high-income countries from health worker emigration from the poorest countries.9 Putting aside questions of moral responsibility, other countries too control policy levers that ultimately affect the outcome. Although sub-Saharan Africa might not be the dominant origin of the influx of foreign-born nurses to the USA, that country’s health labour market is likely to be an important driver of what has been called the medical carousel,71 a singularly inappropriate metaphor in view of the absence of cyclical characteristics of the pattern, or happy result. The so-called carousel might instead be viewed as a hierarchy of inter-related labour markets, with countries such as the USA sitting near the top of that hierarchy and attracting immigrant health staff from lower-income countries, which in turn fill the www.thelancet.com Vol 367 April 29, 2006
gap with migrants from still lower-income countries. The matching of local training levels, demand, and pay and other working conditions in any country further up the hierarchy will ameliorate the exodus from lowestincome countries. The statistics presented for the UK demonstrate the small success so far of efforts to moderate the effect of health worker migration through a recruitment code introduced in 2001.72 Time will tell whether recent modifications to this code73 render it more effective. Even if such codes prove to be weak ways of controlling labour migration, other policies related to work permits, visas, and licensing seem to increase the costs of immigration and constrain health-worker flows from low-income countries. Such policies have until recently restricted non-EU health worker migration to France and they may be a leading constraint to immigration of health workers from low-income countries to the USA.74 Although not strictly comparable, figures 1 and 2 suggest that the numbers of health workers migrating from sub-Saharan Africa to the UK have recently been an order of magnitude greater than the numbers migrating to the USA. Confronted with labour shortages or lobbying from the health care industry, however, policymakers in various OECD countries have shown a willingness to ease immigration, licensing requirements, or both, for internationally trained health workers.18,75 Language is likely to provide some of the explanation as to why Anglophone countries are most affected by the out-migration problem. These accounts suggest that France and Germany may become more accessible destinations in the near future, raising concerns in particular for the countries of francophone Africa. Outmigration of doctors from the countries of Eastern Europe to Germany that has accelerated in recent years poses fewer immediate difficulties since it is widely accepted that these countries have long been over-medicalised.76 Conflict of interest statement We declare that we have no conflict of interest. Acknowledgments Background research for this investigation received financial support from the UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR), study A41327. McPake is Programme Head of the Health Systems Development Programme which is funded by the UK Department for International Development. The funding source for this work made no contribution to the study design, collection, analysis or interpretation of data. References 1 Sagoe K. Using the diaspora to strengthen health workforce capacity, presentation at the International Organization for Migration seminar on health and migration, Geneva, June 9–11, 2004. http://www.iom.int/documents/officialtxt/en/ pp%5Fdiaspora%5Fsakoe.pdf (accessed Dec 13, 2005). 2 Dovlo D, Nyonator F. Migration by graduates of the university of ghana medical school: a prelminary rapid appraisal. Hum Res Health Dev J 1999; 3: 34–37. 3 Mensah K, Mackintosh M, Henry L. The ‘skills drain’ of health professionals from the developing world: a framework for policy formulation. Medact, 2005. http://www.medact.org/content/ Skills%20drain/Mensah%20et%20al.%202005.pdf (accessed Dec 13, 2005).
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